Whole-Person Care: What It Is and How to Get Started

December 12, 2023


Healthcare spending is on the rise. In 2000, total U.S. health care spend was $1.4 trillion. By 2021, total spend grew to $4.3 trillion. Health plans and regulatory bodies are looking for ways to better manage health care expenditures, measure indicators of health and define success. Whole-person care, sometimes referred to as whole-person health or patient-centered care, is an approach that is growing in popularity as health equity initiatives mature and the social determinants of health become more important factors in success for both Medicare and Medicaid health plans.

What is Whole-Person Care?

Whole-person care recognizes that a small percentage of a person’s overall health is the result of their access to health care services. A person’s environment and social risk factors (SRF), like access to healthy food and stable housing, are a larger influence on an individual’s current health status and predictor of future challenges. Whole-person care also acknowledges how the systems of the body are interconnected and patients require holistic condition management. A patient with a chronic illness is at a higher risk for complications.

For example, many patients with chronic conditions also experience mental health issues like depression, often a result of challenges with chronic condition management. The American Hospital Association estimates that untreated depression combined with chronic illness can increase monthly healthcare costs per individual by $560, on average.

The whole-person healthcare model is part of a comprehensive strategy for delivering preventive care. This approach is proactive and regarded as more cost effective than the current reactive approach by avoiding preventable conditions and hospitalizations for people with unmanaged chronic conditions.

Federal and State Movement Toward Whole-Person Care

Health equity is the first priority area in the Centers for Medicare and Medicaid Services (CMS) National Quality Strategy. CMS drafted a Framework for Health Equity. The goal is to help health plans develop strategies to provide equitable access to healthcare services.

One component of these guidelines is the need to develop a better understanding of how individual populations contend with social determinants of health (SDOH) and implement interventions to reduce health disparities for underserved members. How health plans and government programs report this data will play a major role in the future of plan performance.

Medicaid Mobilizes for Health Equity

Specific state Medicaid programs are beginning to require accountability for Health Equity and the elimination of disparities to participate in government-funded programs through an official Health Equity Accreditation offered by National Committee for Quality Assurance (NCQA). The goal is to end barriers to care based on zip code, race, ethnicity, language, sexual orientation, gender, income and disabilities.

For example, California launched a Whole Person Care pilot program within Medi-Cal, the state’s Medicaid program, with 25 initiatives backed by $20 million in 2019. These entities will identify target populations, share data between stakeholders and coordinate care. They will evaluate progress by tracking individuals and the population. The goal is to provide comprehensive, coordinated care for beneficiaries and improve their health outcomes.

The participants in the pilot program include: 

  • High utilizers
  • People with chronic physical conditions
  • Severe mental illness and/or substance use disorder
  • Homeless
  • At-risk-of-homelessness
  • Justice-involved
  • People with Covid-19

Also in California, the 2019-20 Governor’s Budget provided $100 million through the State General Fund for active Whole Person Care Pilot programs that provide housing services.

Star Ratings and Social Risk Factors

To focus Medicare Advantage plans on reducing health disparities for vulnerable populations, CMS is phasing out the Rewards Factor from the Star Ratings program and replace it with the Health Equity Index (HEI). Like the Rewards Factor, the HEI will provide bonus points to Star Ratings, but only for plans who improve health outcomes for members with specific SRF.

The HEI will begin with a subset of SRF, including members who are considered low-income subsidy (LIS) or dually eligible (DE) for Medicaid and those who qualified for Medicare due to a disability. By comparing quality performance for SRF populations against national averages, CMS will calculate HEI rewards. While CMS will start with only a handful of SRF and quality measures, Medicare Advantage plans can expect additional changes to the Star Ratings program to deliver whole-person care.

New HEDIS Screening Measure

To meet the demand for more inclusive reporting standards, the NCQA will also implement a new Healthcare Effectiveness Data and Information Set (HEDIS) measure that catalogs members’ SRF and their race, ethnicity, and language.

Starting in 2024, the Social Need Screening and Intervention (SNS-E) HEDIS measure will require health plans to screen members for unmet social needs related to food, housing and transportation and provide appropriate intervention within 30 days of a screening. While it will only be used for reporting at this time, CMS and state health agencies may incorporate the measure into future quality incentive programs.

How Plans Can Get Started

Implementing a whole person care model starts with capturing a diverse range of SRF data and using that data to guide member engagement strategies. Here are three tactics plans can use to streamline this process.

Optimize Health Risk Assessments

Health risk assessments (HRA) are a valuable tool for capturing this type of self-reported data across membership populations. An HRA is a concise health and wellness survey that asks patients to share information related to their medical history, personal demographics and SRF. HRAs capture valuable member data and allow plans to create roadmaps for improving health outcomes and creating interventions for members.

Here’s a look at what a well-designed HRA should include:

  • A member-friendly format that empowers members to complete surveys in a timely manner
  • Questions on race, ethnicity and language, sexual orientation and gender identity, and SDOH
  • A digital-first format that allows members to submit responses through web portals and mobile apps
  • The option to complete a paper survey for members with limited internet access
  • Relevant rewards to motivate members for higher completion rates
  • The support of omnichannel outreach to encourage members to complete HRAs

Stratify HRA Results

HRAs help health plans identify meaningful patterns indicating the existence of health disparities in subsets of member populations. When conducted digitally, plans can efficiently access results and speed up their ability to stratify member data. Plans can use this information to develop insights into how those disparities play out in different communities in order to reduce them.

Implement Data-Driven Interventions

Once a health plan identifies and understands how SRF impact member health outcomes, they can begin developing targeted engagement campaigns to close care gaps.

Here’s one scenario. Imagine a community in which members with limited English proficiency living in rural areas encounter challenges renewing prescriptions due to a lack of pharmacists with the appropriate language skills, leading to low medication adherence rates.

Care teams could work with translators and bilingual staff to contact members in their preferred language and through their preferred channels to help them sign up for home delivery prescriptions and 90-day refills. By directly engaging with these members, plans could help facilitate further conversations about barriers to care and allow plans to improve member experiences and improve engagement in their healthcare.

This information could be funneled into member engagement strategies and help plans develop more targeted approaches to deliver holistic care, particularly for underserved ethnic and racial groups. Federal, state and regional governments are pushing plans to develop and use this kind of personalized outreach to advance health equity.

Achieve Whole-Person Care with Healthmine

Meeting policy demands to deliver whole person health care requires a strong foundation in data collection, member engagement and interoperability. Healthmine’s digital suite of solutions enable health plans to meet these policy demands and support the necessary data collection infrastructure and engagement strategies to build whole person care programs.

Adopt a whole person model of care to reduce healthcare costs and achieve emerging regulatory requirements. Contact us for a demo.